Services
Clinical Denials and Appeals
Overview
Healthcare providers face difficult challenges with managing clinical denials and appeals, which can impact their ability to get paid in full for the services they deliver. These denials of payment are based on medical necessity, clinical validation, length of stay, or level of care and may be concurrent (while the patient is still in-house) or retrospective (after the patient is discharged).
AGS Health provides seasoned, experienced clinical resources to support clinical denials and appeals processes to mitigate these challenges. We review denied claims, identify root causes, and craft compelling appeals supported by comprehensive clinical evidence. Leveraging our deep understanding of healthcare regulations and payer requirements, we advocate on your behalf, maximizing your revenue and minimizing financial losses.
SERVICES PROVIDED
Clinical denials and appeals can be handled within clinical authorizations, clinical documentation integrity (CDI), or utilization review (UR).
Clinical denials and appeals services provided include:
- Review and analysis of denials focusing on medical necessity, MS DRG/APR DRG downgrades, length of stay, level of care, and subsequent appeals to dispute clinically based denials.
- Corresponding with physicians and hospital departments regarding documentation and supporting clinical indications to defend claims.
- Writing professional letters of appeal.
- Reporting and education on denial trends and critical findings.
- Swift submission of clinical appeals to prevent revenue leakage.
- Simplify revenue cycle management (RCM) workflow and processes.
BENEFITS
Maximize Revenue
Recoup revenue that might otherwise be lost through timely review of denied claims to identify root causes and submitting appeals supported by comprehensive clinical evidence, enhancing financial stability.
Enhanced Efficiency
Prevent revenue leakage and simplify workflows through a streamlined approach that increases standardization and reduces manual errors.
Ensure Compliance
Ensure compliance with complex healthcare policies with thorough and correct documentation and claims handling that aligns with healthcare regulations and payer requirements.
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Additional Clinical Administrative Services to streamline your revenue cycle
Clinical Documentation Integrity Services
A combination of retrospective, prospective, and concurrent reviews of clinical documentation provides precision and specificity in clinical documentation tailored to inpatient and ambulatory settings.
Utilization Management Services
Provide appropriate, efficient, and cost-effective care consistent with current medical standards, preventing unnecessary procedures and optimizing treatment plans to enhance patient outcomes, streamline resource utilization, and drive healthcare excellence.
Clinical Prior Authorization Services
Secure clinical authorizations for complex medical cases, including prior authorizations (prospective) and concurrent authorizations, to ensure proper reimbursement and timely delivery of care aligned to payer contracts.
Physician Advisory Services
Skilled physicians and healthcare professionals provide customized solutions to optimize clinical documentation, coding accuracy, and revenue integrity.
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